2.1. Case presentation
A 64-year-old male on the heart transplant waiting list was admitted to the Cardiovascular Surgery ward of our hospital for intracerebral hemorrhage. He had undergone LVAD (HeartMate II, Thoratec Corporation, Pleasanton, CA, USA) implantation at 59 years of age due to dilated cardiomyopathy causing left ventricle failure. The subcortical hemorrhage was treated conservatively and the patient was rehabilitated in the same ward without any complications. However, the patient developed fever, nausea, and right upper quadrant pain with shock vitals. Computed tomography revealed an enlarged gallbladder with a thickened wall and surrounding fatty tissue opacity. He was diagnosed with acute cholecystitis and was referred to our department. Emergent surgery was considered. However, conditions were not favorable due to the infection and heart failure with an LVAD. Thus, PTGBD was performed to reduce inflammation in the gallbladder. The cholecystitis resolved in a few days. An elective LC was planned for 3 months after the PTGBD, to avoid the risk of recurrent cholecystitis that could cause LVAD infection.
The patient was taking 3.5 mg/d of warfarin with a prothrombin time-international normalized ratio of 2.0–3.0 because of the LVAD. In preparation for surgery, the anticoagulation was reversed with prothrombin complex concentrate. After induction of general anesthesia, markings were made on the skin along the subcutaneous driveline to avoid injury during trocar insertion (Figure 1). The first endoscopic trocar was inserted via the open method (15 mm vertical incision at the umbilicus). The pneumoperitoneum pressure was set at 10 mmHg and a 30° scope was inserted. The other trocars were placed as demonstrated in Figure 1. No adhesions were found around the LVAD, which was placed in the preperitoneal space. However, some adhesions were found around the gallbladder (Figure 2a, b, Additional File 1: Video S1). The neck of the gallbladder was thickened and a sub-total resection was performed. To ensure that there was no postoperative bleeding, a drain was placed in the liver bed and the operation was completed. The duration of surgery was 114 min, and the estimated amount of blood loss was 5 mL.